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Private Duty Nursing Services
Paula Clark, Sr. Policy Advisor, Policy DevelopmentDaneen Machicek, BSN, RN, Acute Care Utilization Review
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Introduction
Private Duty Nursing (PDN) Services
The purpose of this training is to provide information related to:
Skilled and unskilled nursing tasks.
The role of the RN
Clinical documentation
Specific components of PDN policy
A review of several PDN Request Scenarios
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Private Duty Nursing ServicesTexas Medicaid Policy - Benefit Description
PDN services provide nursing care and parent/guardian/responsible adult training and education intended to: Optimize client health status and outcomes. Promote family-centered, community-based care as a component
of an array of service options by: Preventing prolonged and/or frequent hospitalizations or
institutionalization. Providing cost-effective and quality care in the most
appropriate, least restrictive environment.
32/2017 TMPPM Home Health and Private Duty Nursing Handbook
Private Duty Nursing ServicesTexas Medicaid Policy - Benefit Description (continued)
PDN services are nursing services ordered by a physician, included in the nursing plan of care (POC) and provided by an RN or LVN.
42/2017 TMPPM Home Health and Private Duty Nursing Handbook
Texas Medicaid Medical Policy –
The Texas Medicaid Provider
Procedures Manual (TMPPM)
The TMPPM’s Home Health Nursing and Private Duty Nursing (PDN) Handbook includes:
PDN Benefit Description
Medical Necessity Criteria
Specific guidance related to various aspects of the PDN benefit and service
References to Home Health Skilled Nursing Services and Personal Care Services Policies
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HHSC Managed Care Contracts
“Medicaid MCOs must provide the services and benefits described in the most recent Texas Medicaid Provider Procedures Manual and any updates to the Manual. “ UMCCM (2.20), Attachment B-1,
Section 8, 8.1.2 Covered Services
STAR Health Contract – Attachment B-1, Section 8, 8.1.2 Covered Services
STAR Kids Contract – Attachment B-1, Section 8, 8.1.2 Covered Services
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What is professional nursing?
Texas Board of Nursing defines professional nursing:
Observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes
Administration of a medication or treatment as ordered by a physician
Development of the nursing care plan
Retrieved from https://www.bon.texas.gov/practice_scope_of_practice_rn.asp
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Skilled and Unskilled TasksSkilled Tasks Use educated, professional nursing judgment, critical
thinking and experience to make decisions and perform tasks
Unskilled Tasks The task does not require nursing judgement
Usually considered ADLs and IADLs
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Home Health Skilled Nursing
and Home Health Aide Services
Home health skilled nursing (SN) and home health aide (HHA) visits are a benefit of Texas Medicaid Title XIX Home Health Services when a client requires nursing services for an acute condition or an acute exacerbation of a chronic condition that can be met on an intermittent or part-time basis.
Texas Medicaid Medical Policy -
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2/2017 TMPPM Home Health and Private Duty Nursing Handbook
Personal Care Services (PCS)
PCS are support services provided to promote the child or adolescent’s well being in the family or community.
PCS are provided to clients who meet the definition of medical necessity and require assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health maintenance activities (HMAs).
PCS are necessary when a client is unable to accomplish these activities due to physical, cognitive, or behavioral limitation caused by a disability or chronic health condition.
Texas Medicaid Policy -
102/2017 TMPPM Children’s Services Handbook
Skilled Nursing is not meant to
provide Respite or Childcare
PDN is not meant to replace parents or other legally responsible adults.
PDN services that are intended to provide mainly respite care; child care; and/or do not directly relate to the client's medical needs or disability are not a benefit of Texas Medicaid.
The delivery of PDN services may inherently result in the relief of the parent/guardian/responsible adult, child care,and/or some nonmedical, non-skilled activities
in the course of providing nursing care.
112/2017 TMPPM Home Health and Private Duty Nursing Handbook
Private Duty Nursing ServicesPDN Request Case Scenarios Review cases for:
PDN or HHSNV PDN or PCS Greater than 1:1 Ratio
Walk through each request : Medical History Medications Nursing needs Other Supports Psychosocial Current Status/Nursing Notes 24 Hours Flow Sheet
Service Recommendation Policy Highlights
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What documents do you need to
help determine PDN Hours?
Nurses notes (2 weeks to 1 month prior to the request) Home Health Plan of Care Nursing Addendum (summary, rationale and 24 Daily Flow Sheet) Information from a peer to peer phone call (in some cases)
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Case Example #1 - Jimmy
Jimmy is a 3 year old male
Request for 40 hours PDN per week (recertification)
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Case Example #1 – Jimmy
Recommendation: Skilled nursing visits with PCS attendant services. However, since patient is currently receiving PDN will allow wean down schedule to allow parents to adjust schedules.
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Case Example #1 – Jimmy
Policy Highlights: 2/2017 TMPPM, Home Health (HH) Nursing and PDN Handbook , HH Skilled Nursing (SN) and Home Health Aide Services, 3.2 Part-time is defined as SN or HHA visits provided less than eight hours
per day for any number of days per week. Part-time visits may be continuous up to 7.5 hours per day (not to exceed a combined total of three 2.5 hour visits).
Intermittent is defined as SN or HHA visits provided for less than eight hours per visit and less frequently than daily. Intermittent visits may be delivered in interval visitsup to 2.5 hours per visit, not to exceed a combined
total of three visits per day.
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Case Example #2 – Sue
Sue is an 8 year old female
Request for 168 hours PDN per week (recertification)
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Case Example #2 – Sue
Recommendation: Current nursing hours should remain at 168 hours per week.
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Case Example #2 – Sue
Policy Highlights: 2/2017 TMPPM, 4, PDN Services- CCP, 4.1.2 Because Texas Medicaid is obligated to provide all medically
necessary PDN services, a parent or guardian is not obligated to provide PDN services even if the parent or guardian has received the appropriate training. Medically necessary PDN services will not be denied to clients based on the parent or guardian’s ability to provide the necessary PDN services.
The delivery of PDN services may inherently result in the relief of the parent, guardian, or responsible adult,child care, or some nonmedical, nonskilled
activities in the course of providing nursing care.
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Case Example # 3 – John
John is an 8 year old male
Request for 60 hours PDN per week (Initial Request)
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Case Example # 3 – John
Recommendation: Skilled Nursing visits and PCS
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Case Example # 3 – John
Policy Highlights: 02/2017 TMPPM, Children’s Services Handbook, 2.11 Personal Care Services (PCS) (CCP), 2.11.2 PCS are support services provided to clients who meet the
definition of medical necessity and require assistance with the performance of ADLs, instrumental activities of daily living (IADLs), and health maintenance activities (HMAs) due to a physical, cognitive, or behavioral limitation related to a client’s disability or chronic health condition.
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Private Duty Nursing ServicesPDN Services Provided in Group Settings
PDN Services may be authorized in a provider or client ratio other than 1:1
An RN or LVN may be authorized to provide PDN services to more than one client over the span of the day as long as:
Each client’s care is based on an individualized plan of care (POC)
Each client’s needs and POC do not overlap with another client’s needs and POC
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Case Example # 4 –
Mark and Cindy
Mark Request for 140 hours PDN per week
Cindy Request for 146 hours PDN per week
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Case Example # 4 –
Mark and Cindy
Recommendation: 2:1 patient to nurse ration is not appropriate for the two clients above.
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Case Example # 4 – Mark and Cindy Policy Highlights: 02/2017 TMPPM, 4, PDN Services- CCP, 4.1.4.11
PDN Services Provided in Group Settings - PDN services may be authorized in a provider or client ratio other than 1:1.
An RN or LVN may be authorized to provide PDN services to more than one client over the span of the day as long as: Each client’s care is based on an individualized POC Each client’s needs and POC do not overlap with another client’s needs
and POC Settings in which a PDN provider may provide services in a provider-
client ratio greater than 1:1 include, but are notlimited to, homes with more than one clientreceiving PDN, foster homes, or independentliving arrangements. 26
Case Example #5 – Sherlena
Sherlena is a 9 year old female
Request for 40 hours per week (recertification)
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Case Example #5 – Sherlena
Recommendation: Current nursing hours to remain at 40 hours per week.
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Case Example #5 – Sherlena
Policy Highlights:: 2/2017 TMPPM, 4, PDN Services- CCP, 4.1.2 Because Texas Medicaid is obligated to provide all medically
necessary PDN services, a parent or guardian is not obligated to provide PDN services even if the parent or guardian has received the appropriate training. Medically necessary PDN services will not be denied to clients based on the parent or guardian’s ability to provide the necessary PDN services.
The delivery of PDN services may inherently result in the relief of the parent, guardian, or responsible adult,child care, or some nonmedical, nonskilled
activities in the course of providing nursing care.
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Case Example #6 – Sonya
Sonya is a 5 year old female
Request for 48 hours PDN per week (new or recertification)
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Case Example #6 – Sonya
Recommendation: Current nursing hours to remain at 48 hours per week.
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Case Example #6 – Sonya
Policy Highlights: 2/2017 TMPPM, 4, PDN Services- CCP, 4.1.2 Because Texas Medicaid is obligated to provide all medically
necessary PDN services, a parent or guardian is not obligated to provide PDN services even if the parent or guardian has received the appropriate training. Medically necessary PDN services will not be denied to clients based on the parent or guardian’s ability to provide the necessary PDN services.
The delivery of PDN services may inherently result in the relief of the parent, guardian, or responsible adult,child care, or some nonmedical, nonskilled
activities in the course of providing nursing care.
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Questions?
Inquiries about Medical Policy may be sent to Paula Clark
Inquiries about Medical Policy/Utilization Review may be sent to Daneen Machicek,
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Resources Texas Medicaid Provider Procedures Manual –
Home Health Nursing and Private Duty Nursing Handbook
Children’s Services Handbook
Nursing Addendum to Plan of Care and 24 Hour Flow Chart
HHSC Managed Care Contracts and Manuals
Code of Federal Regulations –
CFR §440.80 Private Duty Nursing
CFR § §440.40 (b) EPSDT
Texas Administrative Code –
PDN and PCS Rules
Home Health Services 34
